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Psychoanalytic Psychology © 2015 American Psychological Association 2015, Vol. 32, No. 1, 94–115 0736-9735/15/$12.00 http://dx.doi.org/10.1037/a0038546 THE PSYCHODYNAMIC DIAGNOSTIC MANUAL VERSION 2 (PDM-2): Assessing Patients for Improved Clinical Practice and Research Vittorio Lingiardi, MD Nancy McWilliams, PhD Sapienza University of Rome Rutgers University Robert F. Bornstein, PhD Francesco Gazzillo, PhD Adelphi University Sapienza University of Rome Robert M. Gordon, PhD Allentown, Pennsylvania This article reviews the development of the second edition of the Psychodynamic Diagnostic Manual, the PDM-2. We begin by placing the PDM in historical context, describing the structure and goals of the first edition of the manual, and reviewing some initial responses to the PDM within the professional community. We then outline 5 guiding principles intended to maximize the clinical utility and heuristic value of PDM-2, and we delineate strategies for implementing these principles throughout the revision process. Following a discussion of 2 PDM- derived clinical tools—the Psychodiagnostic Chart and Psychodynamic Diagnostic Prototypes, we review initial research findings documenting the reliability, validity, and clinical value of these 2 measures. Finally, we discuss changes proposed for implementation in PDM-2 and the potential for an updated version of the manual to enhance clinical practice and research during the coming years. Keywords: PDM, DSM, diagnosis, personality, PDM-2-derived clinical tools The first edition of the Psychodynamic Diagnostic Manual (PDM Task Force, 2006) was This document is copyrighted by the American Psychological Association or one of its allied publishers. published during a critical era of change in mental nosology. This period began in 1980 This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. with the publication of the Diagnostic and Statistical Manual of Mental Disorders Vittorio Lingiardi, MD, Department of Dynamic and Clinical Psychology, Faculty of Medicine and Psychology, Sapienza University of Rome; Nancy McWilliams, PhD, Graduate School of Applied and Professional Psychology, Rutgers University; Robert F. Bornstein, PhD, Derner Institute of Advanced Psychological Studies, Adelphi University; Francesco Gazzillo, PhD, Department of Dynamic and Clinical Psychology, Faculty of Medicine and Psychology, Sapienza University of Rome; Robert M. Gordon, PhD, Independent Practice, Allentown, Pennsylvania. Correspondence concerning this article should be addressed to Vittorio Lingiardi, MD, Sapienza University of Rome, Via dei Marsi, 78-00185 Rome, Italy. E-mail: [email protected] 94 PSYCHODYNAMIC DIAGNOSTIC MANUAL VERSION 2 95 (DSM)–III, which represented a shift from a psychoanalytically influenced, dimensional, inferential diagnostic system to a “neo-Kraepelinian” descriptive, multiaxial classification that relied on present-versus-absent criteria sets for identifying discrete mental disorders. This paradigm shift was adopted deliberately, with the aim of removing the psychoana- lytic bias from the manual now that other theoretical orientations were common, including cognitive–behavioral, family systems, humanistic, and biological. The shift was also intended to make certain kinds of outcome research easier: Present-versus-absent traits could be identified by researchers with little clinical experience, whereas the previous classifications (DSM-I and DSM–II) had required significant clinical training to diagnose inferentially many of the syndromes described. Each succeeding edition of the DSM has included more discrete disorders (see Clegg, 2012). The publication of DSM–IV (Amer- ican Psychiatric Association, 1994) continued the neo-Kraepelinian descriptive trend, which has been further elaborated and expanded with the recently published DSM-5 (APA, 2013). Although the DSM is considered by many as a permanent fixture in the world of mental health—a set of guidelines and diagnostic criteria that, for better or worse, will always guide our clinical work—this belief is based more on history and habit than anything else. The DSM-I (American Psychiatric Association, 1952) was published just over 60 years ago. The manual is not a government document (although the development of DSM-I was in part a government effort), nor is it in any way related to policies and procedures endorsed by the National Institute of Mental Health (see Insel, 2013). The DSM is not the most widely used diagnostic system today: The International Classification of Diseases (ICD-10; World Health Organization, 2004) takes that prize. Despite its aura of inevitability, the current version of the diagnostic manual, the DSM-5 (American Psychiatric Association, 2013), is a privately published book, a product of the American Psychiatric Association, intended to guide the professional activities of mental health professionals, but also to shape the reimbursement policies of managed care organizations and to fund various activities of the association. Although early editions of the manual were applauded for systematizing what had been, prior to World War II, a somewhat chaotic array of overlapping diagnostic systems emerging from different theoretical traditions, more recent editions of the DSM have been increasingly controversial (see, e.g., Cooper, 2004; Vanheule, 2012). Beginning in Octo- ber of 2014, the Health Insurance Portability and Accountability Act (HIPPA) has required clinicians to provide ICD-10—not DSM-5—codes for reimbursement. More- over, although advances in biological and cognitive research have tended to dominate recent discussions of diagnosis, assessment, and treatment, psychoanalytic concepts have undergone a quiet resurgence as well, not only in clinical psychology, but in myriad other This document is copyrighted by the American Psychological Association or one of its allied publishers. subfields (e.g., cognitive, social, developmental, neuropsychological; see Protopopescu & This article is intended solely for the personal use of the individual user and is not to be disseminatedGerber, broadly. 2013; Wilson, 2009). Recent critiques of the DSM have touched upon its problematic political and economic aspects, but they have not ended there. Clinicians and clinical researchers have also questioned the DSM emphasis on a disease model of psychopathology, which works better for some syndromes (e.g., schizophrenia) than others (e.g., narcissistic personality disor- der). Critics have noted the expansion in the number of categories in DSM-5 (Batstra & Frances, 2012; Frances, 2013), and have questioned the Kraepelinian nature of DSM diagnoses, with their continued adherence to categorical classification, even for those disorders which may be best conceptualized as reflecting continua of functioning, with no sharp cutoff between normality and pathology (see Craddock & Owen, 2010; Livesley, 2010). Beyond questions regarding the overarching framework of DSM-5 (Good, 2012; 96 LINGIARDI ET AL. Zimmerman, 2012), and its choice of syndrome and symptom descriptors (Huprich, 2011), much of the current opposition to DSM-5 may be seen as a product of the process used to create it (Bornstein, 2011). Any classification system that is based on the work of a committee (or set of committees) will never be completely free of politics and personal preference. Nonethe- less, as a number of writers have pointed out—including some who were involved in earlier DSM revisions (e.g., Frances, 2011; Livesley, 2010; Widiger, 2011)—the DSM-5 revision process differed from earlier efforts in ways that have concerned many research- ers and practitioners. First, the process of developing DSM-5 lacked the transparency on which good science depends. Even though progress toward DSM-5 was periodically updated online, giving the public some chances to submit comments and observations, it is arguable that the priceless opportunity to have a real open dialogue with the clinical and scientific communities was partially lost. Members of the DSM-5 work groups were asked not to reveal details of their deliberations to other mental health professionals, the media, or members of the public, presumably in an effort to avoid being unduly influenced by those who might have a vested interest in the outcome of work group decisions. Although such a strategy has the advantage of minimizing the potential biasing effects of outside forces (e.g., representatives from managed care organizations and pharmaceutical com- panies), it may foster groupthink, increasing the possibility that decisions will be driven by interpersonal dynamics within work groups (e.g., the persuasive power of individual committee members; see Turner & Pratkanis, 1998). In the absence of a real conversation with the whole community, faux pas such as the proposed deletion of the narcissistic personality disorder were perhaps inevitable (about the controversy over the proposed elimination of some personality disorders in the DSM-5, see Shedler et al., 2010). Second, as several critics (e.g., Bornstein, 2011; Ronningstam, 2011; Widiger, 2011) noted, the reviews of relevant literature by DSM-5 work groups was selective: Large areas of empirical evidence were not considered. The work groups failed to give detailed rationales for their decisions about what to include and what to exclude. Finally, the DSM-5 is mainly based on self-report data. A plethora of evidence from cognitive and social research confirms that people are, at best, flawed perceivers

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